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Medi-Cal Update

Pharmacy | March 2021 | Bulletin 987

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1. Updated CCS COVID-19 Guidance, CCS FAQs and COVID Vaccine Flexibilities

The Department of Health Care Services (DHCS) recently developed and posted the following documents to the COVID-19 Information for Providers & Partners web page to provide Coronavirus disease (COVID-19) related guidance for the California Children’s Services (CCS) Program:

  1. Updated CCS COVID-19 Guidance

  2. CCS FAQs for COVID-19 Flexibilities

  3. Flexibilities for County Staff during COVID Vaccine Administration

These documents are also available on the CCS Letters web page.

2. Rates for Certain COVID-19 Diagnostic Testing HCPCS Codes Updated

Effective for dates of service on or after January 1, 2021, the base payment amount for HCPCS Codes U0003 (Infectious agent detection by nucleic acid [DNA or RNA]; Severe Acute Respiratory Syndrome Coronavirus 2 [SARS-CoV-2] [Coronavirus disease (COVID-19)], amplified probe technique, making use of high throughput technologies as described by CMS-2020-01-R), and U0004 (2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV [COVID-19], any technique, multiple types or subtypes [includes all targets], non-CDC, making use of high throughput technologies as described by CMS-2020-01-R), has been adjusted from $100 to $75.

HCPCS Code Description Current Rate New Rate
U0003 SARS Cov-2 COVID-19 Amp prob high throughput $100.00 $75.00
U0004 COVID-19 lab test non-CDC high throughput $100.00 $75.00

Additionally, the codes listed above will be exempt from the 10 percent payment reductions in Welfare and Institutions Code (W&I Code) section 14105.192, as described at Attachment 4.19-B, page 3.3, paragraph 13 of the State Plan.

An Erroneous Payment Correction (EPC) will be issued for affected claims for codes U0003 and U0004 retroactive to dates of service on or after January 1, 2021.

3. New ICD-10-CM and ICD-10 PCS Diagnosis Codes Related to COVID-19

Effective for dates of service on or after January 1, 2021, the Centers for Medicare & Medicaid Services (CMS) has added new ICD-10-CM codes and ICD-10 PCS codes for diagnoses related to coronavirus disease 2019 (COVID-19). Information and downloads for these codes can be found on the ICD-10 page of the CMS website. Specific billing policy related to this update will be published in a future Medi-Cal Update and Family PACT Update.

4. CCS Program and GHPP Require Separate SAR for Risdiplam

Effective retroactively for dates of service on or after August 1, 2020, the California Children’s Services (CCS) program and the Genetically Handicapped Persons Program (GHPP) require a separate Service Authorization Request (SAR) for risdiplam. This drug is not included in a physician service code grouping (SCG).

Provider Manual(s) Page(s) Updated
Audiology and Hearing Aids
Chronic Dialysis Clinics
Clinics and Hospitals
Durable Medical Equipment
General Medicine
Home Health Agencies/Home and Community-Based Services
Inpatient Services
Local Educational Agency
Medical Transportation
Orthotics and Prosthetics
Psychological Services
Rehabilitation Clinics
Vision Care
cal child sar (8, 9); genetic (10, 11)

5. Mobility Devices in Nursing Facilities: TAR Criteria

Effective for dates of service on or after April 1, 2021, Treatment Authorization Request (TAR) criteria for mobility devices in nursing facilities are established.

Providers must submit specific documentation when requesting authorization for custom mobility devices for recipients residing in nursing facilities. Documentation criteria for both medical necessity TARs and attain and maintain TARs is located in the TAR Criteria for NF Authorization (Valdivia v. Coye) section in the appropriate Part 2, Medi-Cal provider manual.

Medi-Cal requires that for ultra-light wheelchairs, manual tilt-in-space wheelchairs or power mobility devices, the recipient must have a specialty evaluation performed by a licensed/certified medical professional, such as a Physical Therapist (PT), Occupational Therapist (OT) or practitioner who has specific training and experience in rehabilitation wheelchair evaluations and who documents the need for the device in the beneficiary’s home or nursing facility.

The PT, OT or practitioner must have no conflict of interest or financial relationship with the supplier. Records from suppliers/vendors or healthcare professionals with a financial relationship or conflict of interest in the claim or outcome are not considered sufficient by themselves for determining that an item is medically reasonable and medically necessary. For more information, providers may refer to the Durable Medical Equipment (DME): Wheelchair and Wheelchair Accessories Guidelines section in the appropriate Part 2, Medi-Cal provider manual.

Provider Manual(s) Page(s) Updated
Durable Medical Equipment
dura wheel guide (5, 7–10); tar crit nf (4–6, 8–11)

6. Sevenfact Added as a Medi-Cal Benefit

Effective for dates of service on or after April 1, 2021, HCPCS code J7212 (injection, factor VIIa [antihemophilic factor, recombinant]-jncw [Sevenfact], 1 mcg) is a Medi-Cal benefit.

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics
blood (4)
Clinics and Hospitals
General Medicine
blood (4); non ph (15, 29)
Rehabilitation Clinics
non ph (15, 29)

7. Policy Updates to Certolizumab Pegol

Effective for dates of service on or after April 1, 2021, the Department of Health Care Services (DHCS) is updating policy for HCPCS code J0717 (injection, certolizumab pegol, 1 mg) to include additional indications approved by the Food and Drug Administration (FDA).

Certolizumab pegol, a pegylated anti-TNF (tumor necrosis factor) biologic therapy, is approved to use for the treatment of Crohn’s Disease, rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, plaque psoriasis and non-radiographic axial spondyloarthritis.

HCPCS code J0717 may be billed with modifiers SA, UD, U7 and 99.

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics inject drug a-d (43–62); modif used (13)
Clinics and Hospitals
General Medicine
Rehabilitation Clinics
inject drug a-d (43–62); modif used (13); non ph (28)
Pharmacy inject drug a-d (43–62)

8. National Correct Coding Initiative Quarterly Update for April 2021

The Centers for Medicare & Medicaid Services (CMS) has released the quarterly National Correct Coding Initiative (NCCI) payment policy updates. These mandatory national edits have been incorporated into the Medi-Cal claims processing system and are effective for dates of service on or after April 1, 2021.

For additional information, refer to The National Correct Coding Initiative in Medicaid page of the Medicaid website.

9. Updates to the List of Contracted Waterproof Sheeting

Effective for dates of service on or after April 1, 2021, Smart choice Medical Inc. items Avancé Hexasorb Waterproof Mattress Sheeting Protector, Hospital, 36" x 80" and Avancé Hexasorb Waterproof Mattress Sheeting Protector, Hospital, 36" x 80" are added as contracted products on the List of Contracted Waterproof Sheeting.

10. Updates to the List of Contracted Incontinence Absorbent Products

Effective for dates of service on or after April 1, 2021, for additions, June 1, 2021, for deletions and February 1, 2020 for one Smart Choice product (UPN 40857950006006) the List of Contracted Incontinence Absorbent Products is updated. Contracted products are added, updated and/or deleted for manufacturers Attends, Cardinal, Secure and Smart Choice. Product descriptions are also updated for one Drylock product (ILI03200) and one Hartmann product (333607).

11. Update to the List of Contracted Incontinence Creams and Washes

Effective for dates of service on or after April 1, 2021, TENA Cleansing Cream is added as a contracted wash product for Essity HMS North American, Inc. on the List of Contracted Incontinence Creams and Washes.

12. Recommencement of Pharmacy Retroactive Claim Adjustments Remains Paused

The Department of Health Care Services (DHCS) will not resume retroactive pharmacy claim adjustments beginning with the February 11, 2021, warrant date. Recommencement of retroactive pharmacy claim adjustments due to a change in the reimbursement methodology for covered outpatient drugs will continue to be paused until further notice. This pause will apply to all pharmacy claims billed through the Medi-Cal fee-for-service Fiscal Intermediary and includes those claims that were also subject to an alternative payment arrangement.

13. Pharmacy Provider Self-Attestation Process Changes in 2021

Although currently delayed, Medi-Cal pharmacy benefits will eventually be transitioned to and thereafter administered through the fee-for-service delivery system for all Medi-Cal beneficiaries (generally referred to as “Medi-Cal Rx”). The Department of Health Care Services (DHCS) has partnered with Magellan Medicaid Administration, Inc. (Magellan) to provide a wide variety of administrative services and support for Medi-Cal Rx.

Magellan has contracted with Mercer Government Human Services Consulting (Mercer), part of Mercer Health and Benefits, LLC, to administer the annual pharmacy provider self-attestation survey for professional dispensing fee reimbursement. The objective of the next self-attestation survey is to assign professional dispensing fee rates for Medi-Cal enrolled pharmacies beginning July 1, 2021 and ending June 30, 2022.

Despite the current delay to transition Medi-Cal pharmacy benefits and administrative services to Medi-Cal Rx, DHCS, through Mercer, will be initiating the provider self-attestation process in April 2021 for the 2020 calendar year reporting period for those pharmacy providers seeking the higher of two professional dispensing fee rates determined by annual prescription volume. Key changes to the self-attestation process include:

  • The provider self-attestation process for the calendar year 2020 reporting period will begin in April 2021 (in previous years, the survey period was January 15 through the end of February).

  • Mercer, on behalf of Magellan and DHCS, will administer the provider self-attestation survey with options for online submission or an email submission of a Microsoft Excel® formatted template.

  • In addition to the standard online submission, pharmacies will have an additional survey submission option that will allow a bulk submission for multiple locations. The new template will allow a corporate office for chain-affiliated stores under common ownership to submit multiple stores in one self-attestation survey file.

As was done previously, newly approved fee-for-service pharmacy providers that are notified of their enrollment approval after the attestation period closes will receive the higher dispensing fee. However, those same providers will have to attest for subsequent reporting periods in order to continue to be eligible for the higher dispensing fee in subsequent fiscal years.

Provider Webinar Details

A virtual stakeholder information session will be held from 1 p.m. to 5 p.m. on March 25, 2021, to review the new self-attestation survey process and project timeline. Providers can sign up for the self-attestation process overview on the Medi-Cal Pharmacy Attestation Survey registration page.

In the meantime, pharmacy providers may refer to the updated Pharmacy Provider Self-Attestation FAQs for more information.

DHCS reminds the Medi-Cal pharmacy fee-for-service provider community to closely monitor upcoming Medi-Cal pharmacy bulletins for additional information regarding future updates, by signing up via the Medi-Cal Rx Subscription Service.

For updates on Medi-Cal Rx, please visit the Department’s dedicated websites at Medi-Cal Rx and the DHCS Medi-Cal Rx Transition website. In addition, DHCS encourages stakeholders to review the Medi-Cal Rx Frequently Asked Questions (FAQ) document, which continues to be updated as the project advances.

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15. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

Download PDF (Portable Document Format) reader from the Web Tool Box.